Tag Archives: Triggering

Innovate to enable rather than motivate



A perennial issue is how to trigger behaviours that are likely to result in good outcomes for the individual. Smoking cessation, regular exercise, more fruit and vegetables, less alcohol….the list is long. There is no magic bullet. Again I make reference to BJ Fogg who offers the most easily digestible way to ponder the question. He promotes the philosophy that innovation is about making it easier for people to do what they already want to do and then triggering that behaviour until it becomes a habit. There are four scenarios:

High motivation and easy to do

An individual in pain will need very little to trigger the relevant behaviour- i.e. take the pill that is stocked in the cupboard.  It might be enough to suggest:

Why don’t you take something for that headache?

There are many such scenarios ranging from the life threatening to the debilitating.  The symptoms may be enough to trigger the behaviour and act as a ‘signal’ for the patient. Unfortunately many chronic and even life limiting conditions are asymptomatic until complications ensue and the patient may not be motivated simply by knowing they have diabetes or similar with potentially serious complications. The motivation may also wane in time- as happens in the case of many acute infections where as the symptoms abate the motivation to persist with antibiotics drops. The longer the duration of the treatment the less likely that the patient will complete the course.  In the case of life long treatments for asymptomatic conditions the probability is low. On the other hand when a patient has perceived that they can do the needful, for example when someone has sourced advice on how to stop smoking, and is motivated to do so, then a simple ‘trigger’ is enough in many cases. Here is some empirical evidence. Health practitioners can provide such triggers- the results will depend on the extent to which motivation and ability are also aligned. Pharmacists may be able to trigger a medical consultation simply by advising it. Perhaps this is the most fruitful avenue for innovation at a time when people are becoming more enabled to self care.

High motivation but hard to do

Many people find it hard to give up bad habits. The mother whose child has suffered another asthma attack is motivated to stop smoking but may perceive it as difficult to achieve. The man who has gained weight in the last decade may feel that more effort is required than he is able to commit to dieting and exercise.  The teenager who has recently been in hospital may be advised to inject insulin and give up chocolate may soon quit the regimen. Unfortunately much effort is expended on developing programs to ‘enable’ patients to do ‘hard’ things in this context. It is critical that what needs to be done is made easier or perceived as easier. A  ‘facilitator’ trigger in this case would give access to something that is ‘affordable’ in terms of time and effort. Sadly this is also the stomping ground of charlatans who might trigger ‘quick cure’ schemes, things that promise more than they can possibly deliver to vulnerable (highly motivated and paying) individuals. Effective innovation comes from developing better, cheaper treatment regimens and then triggering them as in scenario one above. Often what is developed is not perceived as easier and the innovation fails.

Low motivation and easy to do

In this situation the patient is not motivated to do something from which they might benefit and is easily available. The influenza vaccine is offered at the requisite time each year. Uptake remains a cause for concern. The reasons for poor motivation need careful consideration- they may not be rational and the ‘spark’ trigger- something that will increase motivation to the point where action may be problematic or need a local solution. The challenge is always that motivation is hard to influence- people’s entrenched beliefs are difficult to shift. If the public believes there is a link between a vaccine and a serious illness, it will be challenging to trigger parents to bring their child for vaccination. Much effort is expended on ‘educating’ people who attend health practitioners. Motivation may increase to the point where it can be triggered but the amount of the effort expended by practitioners is governed by Fogg’s formula B=MAT. Practitioners may not behave consistently or effectively for a host of reasons and as has been shown through research this strategy has disappointing results.

Low motivation and hard to do

In many circumstances those who stand to gain the most are the least likely to act on health care advice. People in deprived communities often have fewer choices and have more to contend with then health practitioners are able to address. In these circumstances changing the environment in which people live may have more of an impact then attempting to trigger behaviours that are difficult if not impossible to attain by people with competing priorities. At an individual level a person may get to a point in their life where they are sufficiently motivated and can see a way to achieve a target behaviour. Until then they are unlikely to be triggered

Picture by Hamed Parham

What triggers health practitioners to act?


There are four circumstances in which health practitioners might need to act, again with reference to BJ Fogg.

High motivation and easy to do

Imagine a patient who presents with a typical history of some potentially life limiting pathology. Health professionals are highly motivated to act, not least because failure to respond in these circumstances is the commonest reason for litigation. The presentation of the problem can itself trigger the behaviour one might conceive as appropriate. Think of:

  • Red light = stop
  • Green light = go

There are several such ‘signals‘ in medicine:

What the practitioner senses (sight, hearing, touch)

Abnormal physiological sign- abnormal blood pressure, erratic pulse, rapid breathing.

Sign of pathology- abnormal heart sound, a lump or bump.

What patient says

I’m bleeding, I can’t swallow, I’m going deaf, I can’t see

Did you spot the sign in the picture above? The problem with this scenario is that the signs of symptoms do not always evoke the necessary response. It may be too subtle, it may be presented when the doctor is distracted or it may not be recognised. Unfortunately in some instances the condition may be life threatening and therefore it is critical that the ‘signal’ is reliable. Much effort is expended in training health practitioners to be able to respond when required, unfortunately this effort is rarely maintained beyond the initial years of training.

High motivation but hard to do

This relates to patients who could be offered a treatment that the health practitioner knows might help but is hard to provide in the particular circumstances. Imagine traveling abroad and wishing to communicate with someone who doesn’t speak your language. Or wanting to donate money to a charity and not having access to the means to do it.

The triggers to act in these circumstance are what Fogg has dubbed  ‘facilitator triggers‘. Think of:

  • “Tip jars” at the cash register
  • “Add to cart”
  • ” Click on this link”

There are several such ‘facilitators’ in medicine:

  • In house referral cues
  • Desk top protocols for prescribing unfamiliar drugs
  • Charts with instructions from an expert

This trigger has to be available while the practitioner is consulting the patient. It has to be recognised as relevant to the patient concerned and it has to be reinforced by a good experience when it triggers the relevant action- usually a referral or prescription. The trigger both prompts and makes it easier to act.

Low motivation and easy to do

In these circumstances the practitioner is not motivated to do the action but it is easy to do and that behaviour is triggered by something that increases the motivation.

Think of littering.

In medicine this might include:

  • Prescribing an expensive drug when cheaper alternatives are available
  • Ordering unnecessary tests
  • Ignoring warnings of potential drug interactions

There are several ‘spark triggers‘ for such behaviours in healthcare.

What the patient, their family or an expert say or are perceived to say

I demand /recommend this test / prescription / referral.

How the practitioner is feeling or even the time of day

Tired people will behave irrationally or even irresponsibly (e.g. littering)

What the practitioner believes at the time
  • Promotional material from a pharmaceutical company- pens with company logos

In this case the focus is on removing these triggers or making it more difficult to act on the unhelpful trigger. Health care funders often seek solutions in this category. Occasionally a behaviour is desirable- e.g. referral to an NGO for support, in which case the trigger needs to be generated.

Low motivation and hard to do

When people believe they have nothing to gain from an action and they perceive that is it too difficult to respond the action cannot be triggered.

These circumstances are easy to recognise:

  • Being invited to donate a large sum to a cause that does not resonate with your interests / values
  • Spending time on an activity at great opportunity cost.

Several examples in healthcare include:

  • Offered to do research when there is little or nothing to gain from being involved personally
  • Being invited to specialise in a condition that rarely presents in practice.
  • Asked to employ someone who does not generate value to the business / clinic / institution

Often innovators are urged to find triggers for this category. In the first instance those who wish to promote these behaviours fail to recognise /accept that the practitioner is not motivated and underestimate the cost to that practitioner. One answer may lie in reframing the issue so that either motivation or ability are improved and the behaviour is then more likely to be triggered. Another answer is to accept that it is not possible to for practitioners to do everything we might want them to do.

Picture by Debs